A coroner has warned that future deaths could occur unless action is taken over long ambulance waits in Wales, following the deaths of two women who fell at home and waited hours for help. Emergency services took between 17 and 24 hours from the original 999 calls to arrive at the properties in separate incidents in north Wales last year.
Deaths after long delays
A 999 call for 67-year-old Janet Mary Nixon was first made around midday on October 21 2025 after she fell at home. The caller was told no resources were available and given an estimated arrival time of three hours. Further 999 calls were made at around 9pm and 4am the following day, but no ambulance was able to attend. Help finally arrived at 5.15am on October 22, more than 17 hours after the first call was made. Mrs Nixon died on October 30 from her injuries. An inquest in July 2026 ruled her death as accidental.
Dorothy Esther Evans, 88, fell at a residential care home on New Year's Eve 2025 and, despite being found injured by carers, remained on the floor until the following morning. According to the coroner's report, emergency services were called around 9am on January 3, but no ambulance was available until around the same time the following day. Mrs Evans died on January 9 at Glan Clwyd Hospital in Bodelwyddan, Denbighshire. Causes were listed as blockages in an artery in the lung, a break in the upper portion of the thigh bone, frailty and dementia. An inquest also ruled her death as accidental.
Coroner's concerns
Both reports by John Gittins, senior coroner for North Wales, were sent to Welsh Ambulance Service NHS Trust (WAST), while Mrs Nixon's report was also sent to Welsh Health Secretary Mabon Ap Gwynfor. The coroner stressed that "there is a risk that future deaths could occur unless action is taken". In both cases, Mr Gittins acknowledged that there are various reasons for ambulance delays.
In Mrs Evans' report, he said it was suggested that "there was nothing more" the ambulance service could do and that "only other agencies or organisations could affect change". However, there was no evidence made available about which agencies were being referenced. In Mrs Nixon's report, Mr Gittins said WAST representatives had highlighted that "delays in offloading patients at hospital remain one of the most significant elements in relation to these issues". He added: "I was also advised that there is currently work being undertaken to ensure that, in future, there would not be more than a 45-minute wait for the handover of patients and that such a timescale would provide significant improvements in relation to the availability of resources."
"However, it was not possible to provide a reliable timeframe for this provision, and therefore I remain concerned that it is likely that lives will continue to be lost, until such improvements take effect."
Responses from services
Penny Durrant, interim director of nursing at the Welsh Ambulance Service, said: "I would like to offer my sincere condolences to the families of Mrs Evans and Mrs Nixon. We recognise the distress these circumstances have caused and the seriousness of the concerns raised by the coroner." She added that the service has continued to strengthen the way it assesses and supports patients who have fallen, including through a dedicated falls desk, and is working with health boards and NHS Wales partners to improve ambulance availability, including work to reduce hospital handover delays.
A Welsh Government spokesperson said: "Our deepest sympathies and condolences are with the families affected. We share the coroner's serious concerns – it is unacceptable for patients to be exposed to avoidable risk while waiting for an emergency ambulance." The spokesperson noted that ambulance delays are a whole-system issue, that handover times have improved in recent months but performance remains inconsistent, and that Betsi Cadwaladr University Health Board remains subject to the highest level of intervention, with targeted support focused on patient flow and ambulance handover.
